Provider Demographics
NPI:1346958998
Name:MICHIANA CONCIERGE FAMILY MEDICINE
Entity Type:Organization
Organization Name:MICHIANA CONCIERGE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ-MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:574-546-0654
Mailing Address - Street 1:1217 W PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1930
Mailing Address - Country:US
Mailing Address - Phone:574-546-0654
Mailing Address - Fax:888-815-1434
Practice Address - Street 1:1217 W PLYMOUTH ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1930
Practice Address - Country:US
Practice Address - Phone:574-546-0654
Practice Address - Fax:888-815-1434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty